BMJ 2017;356:j916 doi: 10.1136/bmj.j916 (Published 2017 March 02)
Page 1 of 3
Head to Head
HEAD TO HEAD
Should we commit to eradicating malaria worldwide?
Bruno Moonen cannot accept the iniquitous alternative, but Clive Shiff believes the necessary
huge investment could be better spent
1
Bruno Moonen deputy director for malaria , Clive Shiff associate professor
2
1
Global Health Program, Bill & Melinda Gates Foundation, Seattle, WA, USA; 2W Harry Feinstone Department of Molecular Microbiology and
Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
Yes— Bruno Moonen
The World Health Organization,1 the Roll Back Malaria
Partnership,2 and the United Nations3 all have a vision of a
malaria-free world. The world has already committed to malaria
eradication, albeit without a target date. More importantly,
malaria endemic regions are setting ambitious elimination
targets, showing a clear demand for, and commitment to,
regional elimination and, eventually, global eradication.4-6
Equitable and sustainable
For malaria, eradication is the only equitable and sustainable
solution. Half of the world has already eliminated malaria,7 and,
as Melinda Gates put it in 2007: “Any goal short of eradicating
malaria is accepting malaria; it’s making peace with malaria;
it’s rich countries saying: ‘We don’t need to eradicate malaria
around the world as long as we’ve eliminated malaria in our
own countries.’ That's just unacceptable.”8
commitment to malaria eradication is not a call for a vertical
campaign that would divert scarce resources and replace control
programmes. Instead elimination programmes need to build on
strong control efforts (not replace them); the currently well
funded malaria efforts should form the basis for integrated
infectious disease surveillance and integrated vector
management, as was the case in Sri Lanka.12
In general, a false sense of the feasibility of eradication, often
with a single tool, has historically stifled research and
development. Funding faltered for the Global Malaria
Eradication Programme in the 1960s and the programme ended,
and when parasites became increasingly resistant to chloroquine
and DDT controlling malaria became challenging, especially
in sub-Saharan Africa, because a lack of investment in research
and development meant no alternative tools were available.13
Investment in innovation
The alternative, indefinite control, is not sustainable.
Maintaining financial commitment, especially when the burden
becomes low, is challenging, and history has shown that when
programmes are not adequately funded malaria will resurge.9
Indefinite control would require constant investment in research
and development to stay ahead of an ever evolving parasite and
vector. Countries that eliminate, on the other hand, are more
likely to remain malaria-free.10
Today’s challenges relate to emerging resistance, and the
acknowledgment that malaria cannot be eradicated with the
current tools alone has spurred investment in innovation, often
through public-private partnerships. We now have a robust
pipeline of new molecules for treatment and active ingredients
for vector control as well as investments in vaccine development
and other technologies that either reduce mosquito populations
or make them refractory to transmit parasites to sustainably
prevent transmission.14
The challenges in the polio endgame, operationally and
financially, are obvious reasons for pause. As Chris Whitty,
chief scientific adviser to the UK Department of Health, noted:
“Trying and failing [to achieve] eradication is costly, pulls
resources from other priorities, breeds cynicism, and may
destroy good control programmes. The key, therefore, is not to
call for it where we cannot achieve it, and, for most diseases,
we cannot.”11
That malaria is a disease of the rural poor15 makes it an excellent
candidate for eradication if current trends in urbanisation and
reductions in global poverty continue.16 17 This is not necessarily
the case for other infectious diseases. Interrupting transmission
will become increasingly harder for diseases with
human-to-human transmission as population density increases
and for vector borne diseases like Dengue transmitted by a
vector that thrives in urban environments.18
However, failures in control because of inconsistent funding
are equally expensive,9 and bold and ambitious goals typically
mobilise additional resources that otherwise would not have
been available. Also, it is important to recognise that a
In addition, unlike polio, for which routine vaccination continues
globally, many previously malaria endemic countries no longer
have vertical control programmes for malaria, and failing in one
Correspondence to: B Moonen [email protected], C Shiff [email protected]
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BMJ 2017;356:j916 doi: 10.1136/bmj.j916 (Published 2017 March 02)
Page 2 of 3
HEAD TO HEAD
region does not necessarily pose a global risk because regional
success has already been shown to be sustainable.
Although the vision of a malaria-free world is already broadly
held, a recommitment by the World Health Assembly to malaria
eradication would be a strong sign of support for regional
elimination ambitions. This should not be a commitment to a
campaign that is based on a single tool, effected through an
all-in global effort that needs to continue everywhere until the
last parasite is exterminated.
Instead it should be a global commitment to support parallel
regional elimination efforts combined with sustained investments
in research to develop the necessary tools and tackle the yet
unknown challenges of the future. Given the impressive progress
made in the past 15 years,19 now is the time to commit to
eradicating a disease that has plagued humanity since its origin.
And when we are in the endgame, the world should remember
that at the end of the last century this disease killed more than
a million children every year.
No—Clive Shiff
Without doubt the concept of global eradication of a disease is
a highly desirable goal. This laudable objective has been
achieved only once, with smallpox. Success depended on a
vaccine that imparts long lived immunity after a single
inoculation. Even this simple vaccination at scale required a
huge worldwide commitment in people and supplies until the
last person with symptoms was identified and immunologically
isolated.
This is a top-down strategy, dependent on massive concentrated
funding until finished. This runs counter to the concept of public
health as an integrated, sustained service for the community.
The World Health Organization’s global malaria eradication
programme of the 1950s also required central monitoring to
provide local commitment and oversight.20 It had great success
in eliminating malaria from some 34% of the area originally
assessed as endemic for malaria,21 but it depended on functional
local health infrastructure. Although research projects in Africa
generated much epidemiological data,22 they could not sustain
control, foiling global eradication.23 This resulted in WHO
changing its policy on malaria,24 focusing on drugs to prevent
and reduce deaths—and the policy foundered when chloroquine
failed. Our tools today are essentially similar to those of 60
years ago, with improvements in diagnosis and predicting
outbreaks and new insecticides and bed nets.
There are several reasons why we should promote the
management of health services rather than commit massive
funds to attempt to eradicate malaria in the near future.
Inability to see it through
Eradication of malaria will require major synchronised
commitments, but the governments of many endemic countries
have other priorities.25 Local wars as well as unstable, reluctant,
or impoverished administrations, mean many cannot commit
the concerted effort necessary to achieve eradication. At the
Abuja summit in 2000, African heads of state agreed to control
malaria, yet few have committed adequate resources.
A combination of donor and scientific entities will be needed
for successful eradication efforts. But who will do the
integration? What facilities will be needed on the ground? Who
will fund and audit the process? Several donors operate in most
endemic countries but each with a specific agenda. For example,
some donors provide bed nets only for pregnant women or
children under 5, whereas others place no such restrictions but
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do not evaluate their programmes. Eradication would require
coordination and only WHO could do this, but many donors
will not agree and WHO now lacks funds for the vital expertise
to provide successful coordination.
In any programme to initiate eradication, National health
ministries will be responsible for the complex interventions,
requiring civil servants who are well trained and remunerated
and committed to the programme. However, some endemic
countries struggle to fill such roles,26 hampering sustained
management and coordination of necessary resources.
Countries also lack local staff trained and experienced in
deploying drugs, diagnostics, and insecticides. Lack of career
opportunities for entomologists and epidemiologists discourage
people who trained abroad to return home. These experts are
essential for global eradication. Foreign scientists are less likely
to provide continuity and may be influenced by external
perspectives. Total eradication would require integrated,
comprehensive evidence based management in country, not just
advice. Apart from South Africa, the continent has shown little
commitment so far.
Finally, we have no vaccine for malaria. Vector control depends
on insecticides. Experiments are underway to try to genetically
modify species, but these are unlikely to be introduced soon,
and there are over 40 species that are potential malaria vectors.
Invest in public health
Eradication requires elimination of all cases, even of subclinical
infection,27 meaning that however implemented, eradication
would be costly. And costs would increase greatly when seeking
and curing an exponentially shrinking number of patients.
Proper management of malaria seems the sensible route.
Investing to integrate malaria control into functional local public
health systems would be sustainable at a manageable expense.
It would also help bolster local infrastructure and the local public
health service as well as ensuring that malaria is kept under
control and no longer of public health importance.28 To expend
huge resources in an unstable world trying to eradicate a vector
borne parasite complex that has dormancy (Plasmodium vivax
and P ovale) and a zoonotic base (P knowlesi) seems an
irresponsible alternative to improving the management of public
health in endemic countries.
Competing interests: Both authors have read and understood BMJ policy
declaration of interests and BM declares that the Bill and Melinda Gates
Foundation aims to eradicate malaria by 2040.
Provenance and peer review: Commissioned; externally peer reviewed.
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